Background: Young children with diets lacking diversity with low consumption of animal source foods are at risk of iron deficiency anemia (IDA). Objectives: Our objectives were to determine the ...impact of supplementing diets with 1 egg/d on 1) plasma ferritin, soluble transferrin receptor (sTfR), body iron index (BII), and hemoglobin concentrations and 2) the prevalence of iron deficiency (ID), anemia, and IDA. Methods: Malawian 6-9-mo-old infants in the Mazira trial (clinicaltrials.gov; NCT03385252) were individually randomly assigned to receive 1 egg/d for 6 mo (n = 331) or continue their usual diet (n = 329). In this secondary analysis, hemoglobin, plasma ferritin, sTfR, C-reactive protein (CRP), and alpha-1-acid glycoprotein (AGP) were measured at enrollment and 6-mo follow-up. Iron biomarkers were corrected for inflammation. Ferritin, sTfR, BII, and hemoglobin were compared between groups using linear regression. Prevalence ratios (PRs) for anemia (hemoglobin <11 g/dL) and ID (ferritin <12 microg/L, sTfR >8.3 mg/L, or BII <0 mg/kg) between groups were compared using log binomial or modified Poisson regression. Results: A total of 585 children were included in this analysis (Egg: n = 286; Control: n = 299). At enrollment, the total prevalence of anemia was 61% and did not differ between groups. At 6-mo follow-up, groups did not differ in geometric mean concentration of hemoglobin mean (95% CI); Egg: 10.9 (10.7, 11.1) g/dL; Control: 11.1 (10.9, 11.2) g/dL and inflammation-adjusted ferritin Egg: 6.52 (5.98, 7.10) microg/L; Control: 6.82 (6.27, 7.42) microg/L, sTfR Egg: 11.34 (10.92, 11.78) mg/L; Control: 11.46 (11.04, 11.89) mg/L or BII Egg: 0.07 (0.06, 0.09) mg/kg; Control: 0.07 (0.05, 0.08) mg/kg. There were also no group differences in anemia Egg: 46%; Control 40%; PR: 1.15 (95% CI: 0.96, 1.38), ID PR: 0.99 (0.94, 1.05), or IDA PR: 1.12 (0.92, 1.36). Conclusions: Providing eggs daily for 6 mo did not affect iron status or anemia prevalence in this context. Other interventions are needed to address the high prevalence of ID and anemia among young Malawian children. This trial is registered at www.clinicaltrials.gov as NCT03385252. Curr Dev Nutr 2022;6:nzac094. Keywords: eggs, iron, ferritin, soluble transferrin receptor (sTfR), hemoglobin, anemia, iron deficiency, inflammation, infant and child feeding, animal-source foods
Multiple studies have found associations between hemoglobin concentration (Hb) and cognitive development in children under age 2 y, including development of language and motor skills; however, its ...association with early memory development is less well studied. Our objective was to assess whether hemoglobin concentration was associated with scores on a memory task in a sample of children aged 12–15 months in Malawi.
This analysis includes a subset of children (n = 450) from an ongoing trial evaluating eggs during complementary feeding in 660 Malawian children. Hb was measured using the HemoCue 201 Analyser at baseline, when children were 6–9 months old, and at endline 6 months later. The elicited imitation test, a nonverbal measure of memory, was administered at endline. In the test, children were shown eight novel objects. After a period of spontaneous interaction, children were shown a two-action sequence for each object and asked to imitate it, either immediately or after a delay of 10 minutes. Children were scored on their ability to perform the actions in any order (total actions score, 0–16) and to complete the sequences correctly (total sequences score, 0–8). The association of Hb at each time point with total actions was examined using multiple linear regression and with total sequences, categorized (<2 or ≥2 sequences), using multiple logistic regression. Both models controlled for the spontaneous actions produced, baseline Home Observation for the Measurement of the Environment score, maternal education, maternal age, and household asset index, and endline child age and the Family Care Indicators score.
The mean (SD) Hb at baseline was 10.4 (1.6) g/dL and at endline was 11.1 (1.3) g/dL. The mean (SD) total actions score was 6.8 (3.5), and 52.7% of the children had a sequences score below two. Total actions score was not significantly associated with Hb at either time point (baseline: P = 0.99; endline: P = 0.15). Total sequences score <2 was also not associated with Hb (baseline: P = 0.90, endline: P = 0.14).
Hemoglobin concentration at 6–9 and 12–15 months of age was not associated with memory development at 12–15 months in this sample of Malawian children.
The Bill and Melinda Gates Foundation; UC Davis Blum Center.
Our aim was to develop a 24-hour recall program using open-source language that can be readily adapted for use on multiple platforms and in different settings.
We developed the Open Dietary Recall ...System (OpenDRS), a multi-pass, 24-hour recall survey using the XLSForm programming language. XLSForm operates in Microsoft Excel and is used by several free or subscription-based electronic survey platforms that deploy forms via Android devices or online. The first pass collects a brief list of foods consumed, the second pass collects descriptive details and added ingredients for each food, and the third pass collects portion size estimates. The final pass reviews the recorded data with the option to edit or add foods. The program references external food and ingredient lists in .csv format. These food and ingredient lists are customizable for each survey setting, can be coded to match nutrient composition or recipe tables, and can be amended over the course of a study. Questions or response options can be added or edited to fit study-specific data collection methods. Photos can be incorporated for food identification or portion size estimation. Two case studies from adaptations in Malawi and Haiti will be presented.
OpenDRS was used to collect 24-hour dietary intake data among 6- to 15-month-old children in Malawi, for a randomized, controlled complementary feeding trial. The median number of foods reported was 6, and the median survey duration was 9 minutes. For a national nutrition survey of 6- to 59-month-old children and their caregivers in Haiti, the program was expanded to record recipe data and to capture caregiver and child intakes in one electronic survey form. Recipes reported during the caregiver’s recall can be linked to the child’s recall if both consumed the same mixed dish.
OpenDRS is an open-source 24-hour recall program which has been used in low- and middle-income countries. The XLSForm program for data collection and Stata code for data formatting will be made available to researchers conducting nutrition surveys via the Open Science Framework.
The Bill & Melinda Gates Foundation and GAIN.
Vitamin A deficiency remains a nutritional concern in sub-Saharan Africa. Conventionally bred maize hybrids with high provitamin A carotenoid concentrations may have the potential to improve vitamin ...A status in maize-consuming populations. We evaluated the efficacy of regular provitamin A carotenoid-biofortified "orange" maizemeal (~15 μg β-carotene/g) consumption in improving vitamin A status and reducing vitamin A deficiency in children. This was a cluster-randomized controlled trial in the rural farming district of Mkushi, Zambia. All 4- to 8-y-old children in an ~400-km2 area were identified and grouped by proximity into clusters of ~15-25 children. We randomly assigned clusters to 1) orange maizemeal (n = 25), 2) white maizemeal (n = 25), or 3) a parallel, nonintervention group (n = 14). Children in intervention clusters (n = 1024) received 200 g maizemeal for 6 d/wk over 6 mo; the maizemeal was prepared according to standardized recipes and served in cluster-level kitchens. Staff recorded attendance and leftovers. We collected venous blood before and after the intervention to measure serum retinol, β-carotene, C-reactive protein, and a1-acid glycoprotein. Intervention groups were comparable at baseline, and vitamin A status was better than anticipated (12.1% deficient on the basis of serum retinol <0.7 μmol/L). Although attendance at meals did not differ (85%), median daily maize intake was higher in white (154 g/d) than in orange (142 g/d) maizemeal clusters. At follow-up, mean serum β-carotene was 0.14 μmol/L (95% CI: 0.09, 0.20 μmol/L) higher in orange maizemeal clusters (P < 0.001), but mean serum retinol (1.00 ± 0.33 μmol/L overall) and deficiency prevalence (17.1% overall) did not differ between arms. In this marginally nourished population, regular biofortified maizemeal consumption increased serum β-carotene concentrations but did not improve serum retinol.
Background: Vitamin A deficiency remains a nutritional concern in sub-Saharan Africa. Conventionally bred maize hybrids with high provitamin A carotenoid concentrations may have the potential to ...improve vitamin A status in maize-consuming populations.
Objective: We evaluated the efficacy of regular provitamin A carotenoid–biofortified “orange” maizemeal (∼15 μg β-carotene/g) consumption in improving vitamin A status and reducing vitamin A deficiency in children.
Design: This was a cluster-randomized controlled trial in the rural farming district of Mkushi, Zambia. All 4- to 8-y-old children in an ∼400-km2 area were identified and grouped by proximity into clusters of ∼15–25 children. We randomly assigned clusters to 1) orange maizemeal (n = 25), 2) white maizemeal (n = 25), or 3) a parallel, nonintervention group (n = 14). Children in intervention clusters (n = 1024) received 200 g maizemeal for 6 d/wk over 6 mo; the maizemeal was prepared according to standardized recipes and served in cluster-level kitchens. Staff recorded attendance and leftovers. We collected venous blood before and after the intervention to measure serum retinol, β-carotene, C-reactive protein, and α1-acid glycoprotein.
Results: Intervention groups were comparable at baseline, and vitamin A status was better than anticipated (12.1% deficient on the basis of serum retinol <0.7 μmol/L). Although attendance at meals did not differ (85%), median daily maize intake was higher in white (154 g/d) than in orange (142 g/d) maizemeal clusters. At follow-up, mean serum β-carotene was 0.14 μmol/L (95% CI: 0.09, 0.20 μmol/L) higher in orange maizemeal clusters (P < 0.001), but mean serum retinol (1.00 ± 0.33 μmol/L overall) and deficiency prevalence (17.1% overall) did not differ between arms.
Conclusion: In this marginally nourished population, regular biofortified maizemeal consumption increased serum β-carotene concentrations but did not improve serum retinol. This trial was registered at clinicaltrials.gov as NCT01695148.
Background: Eggs are a rich source of choline, an essential nutrient important for child growth and development. In a randomized trial of 1 egg/d in young children in Ecuador, an egg intervention led ...to significant improvements in growth, which were partially mediated by increased plasma choline concentration. A similar trial in Malawi (clinicaltrials.gov: NCT03385252) found little improvement in child growth or development. Objectives: We aimed to evaluate the effect of 1 egg/d for 6 mo on plasma choline concentrations in Malawian children enrolled in a randomized trial. Methods: Infants aged 6-9 mo in rural Malawi were randomly assigned to receive 1 egg/d (n = 331) or serve as a nonintervention control (n = 329) for 6 mo. Anthropometric, developmental, and dietary data were collected at baseline and 6-mo follow-up, along with a blood draw. Plasma choline, betaine, dimethylglycine, trirnethylarnine N-oxide (TMAO), and DHA were measured at both time points using ultrahigh performance liquid chromatography-tandem MS (n = 200 per group). Linear regression analysis was used to determine the difference in plasma choline and related metabolites between groups after 6 mo of intervention. Results: Plasma choline, betaine, dimethylglycine, and DHA concentrations did not differ between groups at 6-mo follow-up. Plasma TMAO was significantly (26%; 95% CI: 7%, 48%) higher in the egg intervention group in a fully adjusted model. Conclusions: Provision of 1 egg/d for 6 mo did not result in increases in plasma choline or related metabolites, except TMAO. This could partially explain the lack of effect on growth and development. Additional interventions are needed to improve choline status, growth, and development in this population. Curr Dev Nutr 2022;6:nzab1 50. Keywords: choline, trirnethylarnine N-oxide, LMIC, growth, development, complementary foods
In many regions of the world, little is known about meal structures, meal patterns, and nutrient intake because the collection of quantitative dietary intake is expensive and labor-intensive.
We ...describe the development and field feasibility of a tablet-based Tanzania 24-h recall tool (TZ-24hr-DR) and dietary intakes collected from adults and children in rural and urban settings.
Using the Tanzanian food-composition table, the TZ-24hr-DR tool was developed on an Android platform using the Open Data Kit. The module provides food lists, meal lists, ingredient lists, quantity and amount consumed, breastfeeding frequency, and a recipe feature. Similar to the USDA Automated Multiple Pass Method, this TZ-24hr-DR contains review features such as time in-between meals, a summary of meals, and portion sizes.
Dietary intake using TZ-24hr-DR was collected among 1) 845 children 0–18 mo of age enrolled in the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) trial (ClinicalTrials.gov identifier: NCT03759821) in Mara, Tanzania, and 2) 312 adult families from the Diet, Environment, and Choices of positive living (DECIDE) observational study in peri-urban Dar es Salaam. Interviewers were trained on paper-based methods with food models and tablet-based collection. Conversion to nutrient intake was readily linked and accessible, enabling rapid review and analysis. Overall, 2158 and 8197 dietary meal records were collected from the DECIDE study and EFFECTS trial, respectively. Among adults, 63% of men and 92% of women reported eating at home, and there were differences in protein, fat, and zinc. Food consumed outside the home typically occurs for the first 2 meals. Children’s intake of nutrients increased with age; however, median micronutrient intakes for calcium, iron, zinc, and vitamin A remained below recommended nutrient intakes.
The TZ-24hr-DR is a field- and user-friendly tool that can collect large samples of dietary intakes. Further validation is needed. The tool is available freely for research purposes and can be further adapted to other contexts in East Africa.
A tablet-based quantitative dietary intake tool was developed for Tanzania and used to survey 2 populations: rural children and peri-urban adults living with HIV.
Background: In many regions of the world, little is known about meal structures, meal patterns, and nutrient intake because the collection of quantitative dietary intake is expensive and ...labor-intensive. Objectives: We describe the development and field feasibility of a tablet-based Tanzania 24-h recall tool (TZ-24hr-DR) and dietary intakes collected from adults and children in rural and urban settings. Methods: Using the Tanzanian food-composition table, the TZ-24hr-DR tool was developed on an Android platform using the Open Data Kit. The module provides food lists, meal lists, ingredient lists, quantity and amount consumed, breastfeeding frequency, and a recipe feature. Similar to the USDA Automated Multiple Pass Method, this TZ-24hr-DR contains review features such as time in-between meals, a summary of meals, and portion sizes. Results: Dietary intake using TZ-24hr-DR was collected among 1) 845 children 0-18 mo of age enrolled in the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) trial (ClinicalTrials.gov identifier: NCT03759821) in Mara, Tanzania, and 2) 312 adult families from the Diet, Environment, and Choices of positive living (DECIDE) observational study in peri-urban Dar es Salaam. Interviewers were trained on paper-based methods with food models and tablet-based collection. Conversion to nutrient intake was readily linked and accessible, enabling rapid review and analysis. Overall, 2158 and 8197 dietary meal records were collected from the DECIDE study and EFFECTS trial, respectively. Among adults, 63% of men and 92% of women reported eating at home, and there were differences in protein, fat, and zinc. Food consumed outside the home typically occurs for the first 2 meals. Children's intake of nutrients increased with age; however, median micronutrient intakes for calcium, iron, zinc, and vitamin A remained below recommended nutrient intakes. Conclusions: The TZ-24hr-DR is a field- and user-friendly tool that can collect large samples of dietary intakes. Further validation is needed. The tool is available freely for research purposes and can be further adapted to other contexts in East Africa. Curr Dev Nutr2022;6:nzac015 Keywords: tablet, open data kit, dietary data, nutrient intakes, Tanzania, diets, children, adults c The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( Manuscript received October 24, 2021. Initial review completed January 18, 2022. Revision accepted January 26, 2022. Published online February 8, 2022. This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation Grant Number ID: OPP1110043. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. This paper was presented at the American Society of Nutrition (ASN) in Baltimore, MD, USA (2019). The Diet, Environment, and Choices of positive living (DECIDE): Evaluating personal and external food environment influences on diets among PLHIV (persons living with HIV) and families in Dares Salaam, Tanzania, study is funded through the Drivers of Food Choice Grants Program by the Bill and Melinda Gates Foundation (ID: OPP1110043) and the Foreign, Commonwealth, and Development Office (FCDO). The EFFECTS trial is funded by the Eleanor J Crook Foundation and the Conrad N Hilton Foundation. Author disclosures: The authors report no conflicts of interest. The funders did not play a role in study design, implementation, analysis, or interpretation of the data. Supplemental Figures 1 and 2, Supplemental Report 1, and Supplemental Table 1 , and are available from the "Supplementary data" link in the online posting of the article and from the same link in the online table of contents at The DECIDE study is a collaborative project led by Purdue University, University of Chicago at Illinois, Muhimbili University, and Africa Academy of Public Health. Address correspondence to RA (e-mail: rambikap@purdue.edu). Abbreviations used: DECIDE, Diet, Environment, and Choices of positive living; EFFECTS, Engaging Fathers for Effective Child Nutrition and Development in Tanzania; FCT, food-composition table; FFQ, food-frequency questionnaire; IRB, Institutional Review Board; LMIC, low- and middle-income country; ODK, Open Data Kit; PLHIV, persons living with HIV; RNI, Recommended Nutrient Intake; TZ-24hr-DR, Tanzania 24-h recall tool.
We assessed the internal validity of the Food Access Survey Tool (FAST) using data from households (
n
= 907) enrolled in an efficacy trial of biofortified maize in rural Zambia. This scale assesses ...food insecurity over a 6-month recall period. A Rasch partial credit model was used to evaluate item performance. Unidimensionality was assessed by principal component analysis, monotonicity was assessed by non-parametric methods, and differential item functioning (DIF) by several characteristics was assessed by cumulative ordinal logistic regression models. One item (frequency of consuming three square meals) did not fit the partial credit model. The remaining eight items fit in a primary single statistical dimension and item category severity increased monotonically with increasing severity of food insecurity. We identified statistically significant DIF in three subgroup comparisons, but effect sizes of total DIF were considered practically insignificant (<2 %). After excluding the item on “square meals,” the FAST serves as an internally valid tool to measure household food insecurity in rural Zambia.
In many regions of the world, little is known about food consumption, meal structures, meal patterns, and nutrient intake. Collection of these data using quantitative dietary intake is expensive and ...labor intensive. Thus, many programmatic and routine surveillance studies resort to simplified indicators to measure dietary quality. Based on a previous study conducted by Caswell et al. on tablet-based data collection of 24-hour dietary recall (24hr-DR), we have developed and adapted a mobile tool collecting 24hr-DR among adults and children in Tanzania.
Using the Tanzanian food composition table (FCT), the 24hr-DR was developed on an Android platform in Open Data Kit. The module provides food groups, food lists, meal list, ingredient list, quantity and amount consumed, breastfeeding frequency, and a recipe feature to collect detailed information (such as cooked and uncooked weights). Similar to the USDA Automated Multiple Pass Method, to accurately capture the dietary intake the tool contains summary features such as time in between meals and review of meals and portion size consumed in the previous day.
The mobile tool is currently used to collect dietary intake (1) among 960 children 0–18 months of age enrolled in the EFFECTS trial (ClinicalTrials.gov Identifier: NCT03759821) in Mara, Tanzania, and (2) among adult families enrolled in the DECIDE study in Dar es Salaam. Field workers were first trained on paper-based methods with food models followed by training on tablet-based collection. Because the tool was tailored with the Tanzanian FCT, conversion to nutrient intake for the individual are readily linked. This enables the investigators to look at dietary intake data in real time for quality assurance and analysis. Demonstration of the tool along with dietary profiles and analysis will be compared with the literature. The tool will be made available to the public in December 2019, and can be adapted to different contexts.
Using mobile-based flexible platforms linked to a pre-existing FCT demystifies the “black box” processes of converting dietary intake to nutrient intake, thus reducing the time and labor needed using the traditional paper-based 24hr-DR method.
This study is funded through the Drivers of Food Choice Grants Program by Bill and Melinda Gates foundation and UK AID.
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